Imatges de pàgina
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exhibiting an irregular cauliflower appearance. Interspersed through the morbid substance above the joint were several cavities, each containing from half an ounce to an ounce and a half of a glairy gelatinous fluid; and in dissecting the tumour, the knife frequently struck against spicula of bone, which were afterward found to radiate in considerable masses from the femur.-This bone exhibited a white, rough, diseased appearance, denuded of periosteum from its lower extremity to the lesser trochanter.

"Upon examining the stump, which was done by separating the flaps that had united through their entire extent externally, a large spongy mass, not unlike a piece of unhealthy lung, presented itself. On cutting into it we ascertained that it was the divided muscles which were thus strangely altered in so very short a space of time; for during the operation they presented a healthy appearance. It was this swelling of the muscles which caused the tumefaction of the stump already mentioned; for scarcely any fluid came away previous to death, on the introduction of the probe or director.

"The little ichorous matter which did pass off was ascertained to come from the upper part of the wound, where there was a considerable cavity, the bottom of which was formed by the acetabuJum. The viscera of the cavities were also examined, but nothing remarkable was observed respecting them." 167.

This is a disease described by Sir Astley Cooper and M. Boyer, the former terming it fungous exostosis of the medullary membrane, the latter osteo-sarcoma. This discase is not only dreadful in itself, as affecting an extremity, but very often so engrafted on the constitution, that the operation of amputation gives but a temporary respite from its ravages. We shall here introduce a case which lately fell under our own notice, and which will put the junior practitioner on his guard against entertaining too sanguine hopes when he has to deal with this formidable disease.

"Miss Burnet, ætat. 16, tall, slender, and of the strumous appearance, experienced a fall on the left knee, about seven months previously to Christmas, 1815. Ever after that period she felt pain in that joint. In December, a small swelling was perceived on the inner condyle, which gradually increasing, spread round the upper part of the joint; and by the 22d of May, 1816, it had attained the size of a very large man's head, and extended about half way up the thigh. It was uniformly hard, and seemed equally to embrace the femur and upper part of the joint. The colour was not altered, but large blue veins were then apparent on its surface.

"By the beginning of August, 1816, it had attained very rapidly a much greater size, and measured 26 inches in circumference. It now projected much more on the inner than on the outer side of the thigh, and was softer there than formerly. It afforded some obscure indications of a contained fluid. All remedial measures had proved unavailing in arresting the progress of the tumour; the poor girl's

strength was fast declining, and hectic fever was beginning to deve lope itself. Much diversity of opinion existed relative to the nature of the disease; but it was universally agreed that nothing but an operation could offer a prospect of life.

Operation, 13th August, 1816. The first incision (slantingly longitudinal between two large veins) half, or three quarters of an inch in depth, and five or six inches in length, disclosed nothing but unhealthy or gelatinous-looking cellular and adipose substance. The next incision went through the fascia, when a considerable quantity of blood and serous fluid boiled out from the turgid vessels of the tumour, a tourniquet being now moderately tightened on the thigh, near the groin. The deeper incisions developed a mass of disorganization, of various textures and appearances; some parts resembling cerebrum; some condensed cellular substance; some ligament; some jelly; some marrow; and some diseased fat. Throughout the greater extent of the tumour were interspersed very many cells, bags, or cavities, of extremely irregular shapes, filled with fluids, principally serum and coagulable lymph; but, in some places, coagulated blood, apparently recently extravasated; and in several of these sacs were found afterward, on more minute dissection, ill-conditioned purulent matter, very thick in consistence. The artery was traced (after the limb was removed) from the triceps, through the ham, to the leg, but was perfectly pervious and sound. The condyles of the femur were amazingly enlarged and diseased. They were spread to full six inches in breadth; and in some cases so soft, that the scalpel went through them, in all directions, without meeting more resistance than was offered by the circumvesting integuments. The cartilages of the femur were not abraded; but they readily stripped off the condyles of the bone, which were so rotten and soft underneath, that the finger could be pushed into them. The semilunar cartilages were apparently unaffected; but the crucial ligaments were rotten. The head of the tibia, especially on the inner side, was scabrous, spongy, and carious. The cartilage was abraded off the internal edge of the patella, and the bone itself was scabrous and diseased in that place. The articulating cartilages of the tibia were every where sound. The body of the femur was diseased and enlarged, for the space of eight inches from the joint. Towards the condyles it was soft and carious; but upwards, towards the middle of the bone, it was enlarged, and pretty hard. Several calcareous depositions were found scattered through different parts of this tumour.

"Two portions of the cerebroid substance were put, one into sulphuric acid, and the other into water. The former was soon dissolved, and formed a black, oily, homogeneous liquid; the latter rendered the water turbid, but did not dissolve.

"Mr. Burns mentions his having seen white swelling and fungus hæmatodes united in the same tumour; and the present case appears to confirm this assertion. Various were the opinions, both before and after the removal of the limb, respecting the nature of the

disease. Several able men, who had not seen the progress of the tumour, pronounced it aneurism, even on the day of the operation. "The thigh was removed at the little trochanter, and half a minute's dissection would have liberated the head of the bone from the acetabulum. Would not this be a better plan of amputating at the hip joint, after all that has been said on the subject?-The girl recovered; but she nearly expired on the table. Med. Chir. Journ. vol. iii.

About eighteen months afterward the young lady died of an obscure internal complaint, and we had an opportunity of examining the body. A large tumour similar to the one above-described rose from the spine, pressed the heart towards the right side of the thorax, and so much encroached upon the lungs as to wear the unhappy patient out with dyspnoea, fever, and irritation.

ART. VII. Case of Cynanche Laryngea, in which the Operation of Tracheotomy was performed with success. Also a Case of Abscess between the Esophagus and Cervical Vertebræ, &c. &c. By R. CARMICHAEL, Esq.

AMONG the triumphs of modern surgery, successful tracheotomy holds a distinguished place. These operations are now becoming very common. A life was preserved a few months ago, at Bartholomew's Hospital by this operation, under circumstances of inflammation which, some years back, would not have been thought remediable by tracheotomy.

I. The first patient which Mr. Carmichael operated on, was a robust female, 30 years of age, who was admitted into the Whitworth Hospital on the evening of the 8th of May, affected with dull pain in the larynx, and a sense of constriction there, which greatly impeded respiration. These symptoms increased, without any tumour externally, but with a slightly increased vascularity of the mucous membrane lining the internal fauces. The right tonsil was enlarged, and the uvula rigid, with its tip looking forwards, and placed at right angles with the velum. Pressure on the tongue with a spoon gave relief to the breathing, pulse 108. History given by the patient was, that six days ago, after leaving off her cap, she was seized with pain in both ears, which was soon followed by symptoms of laryngitis. An emetic was administered to clear the bronchial tubes, and antimonials every four hours afterward. No alleviation followed; and next day twelve leeches were applied to the external fauces, which also failing of effect. fourteen

more were applied. These measures produced not any relief. Five grains of calomel, and one-third of a grain of opium were ordered every third hour. As death was now threatened, Mr. Carmichael was called in, and immediately proceeded to the operation. We must here express our surprise that a young, robust, and plethoric patient should have been allowed to labour under acute inflammation of such a part as the larynx until tracheotomy was necessary, without ever opening a vein. We have no hesitation in asserting that the patient should have been bled to syncope on first entering the hospital-that immediately afterward the whole throat should have been covered with leechesthat the bowels should have been briskly acted upon-that the force of the vascular system should have been kept under control by digitalis and antimony--and that a blister to the sternum should have succeeded general and local bleeding. We know from experience that these measures have more than once arrested the progress of a more violent laryngitis than appears to have existed in the above case. Such decisive measures should never be omitted in this inflammation.

"The external incision (between the inferior edge of the thyroid gland and the sternum) was about an inch and a half in length, and the hæmorrhage was so inconsiderable that there was not more than half an ounce of blood lost during the operation; for owing to the steadiness of the patient, and a clear light, the large veins on the forepart of the trachea were distinctly seen, and avoided. The incision into the trachea was first made by dividing the membranous substance between two of the rings; then the inferior of the two was divided by a perpendicular incision, and this opening was enlarged by laying hold of one edge of the divided ring with a forceps, drawing it forwards, and cutting off a slice with a knife.-A similar piece being removed from the other edge of the divided ring, a square opening was left sufficiently large not only for the easy passage of air, but of mucus-a circumstance of the greatest moment with respect to the success of the operation, for if the opening should not be large enough to admit of the expulsion of mucus, a recurrence of a state of suffocation must ensue from its accumulation in the trachea and larynx, as there is little chance of its being expelled by the glottis, now that the patient breathes through the wound in the trachea. The removal of a piece of one or two of the rings, as recommended by Mr. Lawrence, is therefore, in my opinion, far preferable to the introduction of a canula, for the latter is not only a source of great distress, but is by no means equal to the other for admitting of the easy exit of mucus. If we are contented with merely dividing the membranous substance which connects the rings, recourse must be had to the canula, as the opening will soon become clogged with mucus in spite of all the efforts of the patient to expel

it; and for obvious reasons we should prefer a canula of as large a diameter as can be introduced." 175.

We do not quite agree with Mr. Carmichael in some parts of the foregoing quotation. In many cases there will be an absolute necessity for the canula-and that for a considerable time. In the case related at page 438 of the first volume of this series, the tube has been worn five years. In a case lately operated on in St. Bartholomew's hospital, we believe the tube was worn at least two months, if not more. We admit indeed that if the opening be made only between two of the rings, it will be too small; but we know that a longitudinal slit through a couple of rings will readily admit a flattened tube, especially if a piece of flattened bougie be introduced into the tube, so as to give it a blunt end as it were. The bougie is, of course, to be withdrawn so soon as the tube is in.

As soon as the trachea was opened the patient experienced inexpressible relief, and soon fell fast asleep, which continued most part of the night. Next day, however, the difficulty of breathing returned, and it was evident that the aperture in the trachea was not of sufficient calibre.

"The difficulty of breathing continuing to increase, a bistoury was introduced in the evening, by which the opening was enlarged upwards. The good effects of this enlargement became soon evident, for the patient lay down on her side for the first time since the performance of the operation, and slept soundly for two hours."

From this time the patient progressively mended, and was discharged from the hospital in about three weeks after the operation.

Case II. This operation of tracheotomy was performed about the same time as the other, but was unsuccessful. On the 14th May, Mr. C. was summoned to the aid of a woman in the Dublin Female Penitentiary, whom he found sitting erect in bed, respiring with difficulty, and with a loud, stridulous noise, her head thrown back, and her chin brought forward, in a convulsive manner, at each inspiration. Her countenance was pallid, her skin below the natural temperature, and her pulse from 120 to 130.

Mr. C. learnt that the patient had complained of pain in her throat upward of a month, attended with difficulty of deglutition and respiration, for which local and general bleeding, blistering, and other remedies, had been tried by Dr. Mills, without affording relief.

"On examining the fauces, I could not perceive any swelling of the tonsils, or of the posterior part of the pharynx. The entire front

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